Utility of a Steerable Microcatheter for the Selective Transvenous Embolization of Dural Arteriovenous Fistulas.

Objective: Selective transvenous embolization (sTVE) is an effective technique for treating dural arteriovenous fistulas (DAVFs); however, selective catheterization into the shunted pouch is often difficult due to the acute angle of the access route between the target pouch and dural sinus. We present our initial experience using a steerable microcatheter (SM) to manually control the tip angle for selective catheterization and sTVE of DAVFs. Methods: Thirteen consecutive cases of DAVFs and 16 procedures that involved sTVE using SM between October 2016 and October 2018 were reviewed. SMs were used for selective catheterization of shunted venous pouches and/or the affected sinus and coil embolization. We evaluated the maneuverability of the SM, the success of selective catheterization into the target lesions, and the results of endovascular treatments. Results: Endovascular procedures were performed in a single session in 10 cases and in two staged sessions in 3 cases. There was no difficulty in maneuverability of the SM. Successful selective catheterization was achieved in 26 of 27 target lesions. Immediately after embolization, angiography showed complete occlusion in 10 cases and marked reduction in 3 cases. During 40.9 months of mean follow-up, 12 cases showed complete occlusion and one case showed a small residual shunt on MRI. Procedure-related complications of spontaneous thrombosis of the affected sinus were observed in one case. There were no cases of recurrence or exacerbation during follow-up. Conclusion: SM is useful for selective catheterization for target lesions during sTVE of DAVFs.

Diploic arteriovenous fistulas with marked cortical venous reflux.

Diploic arteriovenous fistulas are rare arteriovenous shunts involving the skull, which often drain antegradely into the internal or external jugular veins. Diploic arteriovenous fistulas with marked cortical venous reflux are extremely rare. Here, we present the case of a patient with diploic arteriovenous fistulas with marked cortical venous reflux and a literature review. A 73-year-old woman presented with headache. Magnetic resonance angiography revealed abnormal signal intensity in the diploic layer of the left frontal bone. Digital subtraction angiography demonstrated a diploic arteriovenous fistulas located in the left frontal bone. The arteriovenous fistulas were fed by multiple branches of the left external carotid artery, mainly from the middle meningeal artery, branches of the ophthalmic artery, and the inferolateral trunk. The fistulas drained into the cerebral cortical veins surrounding the frontal lobe via an emissary vein of the frontal bone. With the femoral arterial approach, transarterial catheterization into the shunted diploic vein was performed with a small tapered microcatheter, and the arteriovenous fistulas were completely embolized with N-butyl-2-cyanoacrylate. The patient was discharged without complications. No recurrent arteriovenous fistulas were observed during the 12-month follow-up period. Endovascular treatment is an effective technique for the curative treatment of diploic arteriovenous fistulas.

Dedifferentiated chordoid meningioma with rhabdomyosarcomatous differentiation on the middle cranial fossa.

A 46-year-old woman presented with headache and right hemiparesis. MRI demonstrated a mass in the left middle fossa. Total resection was performed. A histological examination of the tumor specimen showed several characteristic morphological features. A chordoid meningioma showing an epithelial-like palisade arrangement was observed. An anaplastic short spindle cell tumor exhibiting a fascicular pattern was considered to be a rhabdomyosarcoma. After conventional radiotherapy, the tumor was well controlled without any neurological deficit for 20 months. When subsequent recurrences were observed, the patient was treated by surgery, stereotactic radiosurgery and chemotherapy. Thirty-two months after the initial treatment, the patient died due to intracranial dissemination and an autopsy was performed. The histological examination of the recurrent and autopsy specimens showed a prominent sarcoma component. This case appears to be the first reported intracranial tumor diagnosed as a dedifferentiated chordoid meningioma with rhabdomyosarcomatous differentiation.

Third nerve palsy caused by compression of the posterior communicating artery aneurysm does not depend on the size of the aneurysm, but on the distance between the ICA and the anterior-posterior clinoid process.

OBJECTIVE: Third nerve palsy (TNP) caused by a posterior communicating artery (PCoA) aneurysm is a well-known symptom of the condition, but the characteristics of unruptured PCoA aneurysm-associated third nerve palsy have not been fully evaluated. The aim of this study was to analyze the anatomical features of PCoA aneurysms that caused TNP from the viewpoint of the relationship between the ICA and the skull base. METHODS: Forty-eight unruptured PCoA aneurysms were treated surgically between January 2008 and September 2013. The characteristics of the aneurysms were evaluated. RESULTS: Thirteen of the 48 patients (27%) had a history of TNP. The distance between the ICA and the anterior-posterior clinoid process (ICA-APC distance) was significantly shorter in the TNP group (p<0.01), but the maximum size of the aneurysms was not (p=0.534). CONCLUSION: Relatively small unruptured PCoA aneurysms can cause third nerve palsy if the ICA runs close to the skull base.

An adult case of cerebral malakoplakia successfully cured by treatment with antibiotics, bethanechol and ascorbic acid.

Cerebral malakoplakia is a very rare chronic inflammatory disease. We herein report the case of a 49-year-old female who presented with a slowly progressive speech disturbance and right hemiparesis. Computed tomography and magnetic resonance imaging showed irregular enhanced mass lesions with numerous scattered areas of calcification in the left insula, thalamus and basal ganglia. Histopathologically, the biopsy specimen showed basophilic laminated inclusion bodies and intracellular and extracellular calculospherules, usually with a typical targetoid appearance (Michaelis-Gutmann bodies). Treatment with antibiotics, bethanechol and ascorbic acid improved her symptoms in association with a decrease in the abnormal calcification and enhancement. The cerebral malakoplakia mimicked a brain tumor in terms of the patient's clinical course and neuroradiological image findings; however, it was successfully cured with medical treatment. This case provides evidence that the pathogenesis of cerebral malakoplakia is deeply tied to bacterial infection and that medical treatment is effective in cases of this disease.

[Effect of Gorei-san with tranexamic acid for preventing recurrence of chronic subdural hematoma].

OBJECT: Chronic subdural hematoma is often seen in elderly patients. One burr hole surgery with subdural drainage has been performed and prognosis is good, but the recurrence rate is still about 10%. To prevent the recurrence, we used Kampo-medicine Gorei-san with tranexamic acid after surgery. The purpose of this study is to investigate if the recurrence is able to prevent by using these drugs. METHODS: From January 2008 to December 2010, 199 consecutive cases with chronic subdural hematoma were examined at Nagatomi Neurosurgical Hospital. Patients were divided into four groups according to the administered drugs; Gorei-san, tranexamic acid, Gorei-san with tranexamic acid and no drug groups. The recurrence rate was compared between each group. The chi-square test was performed as a statistical analysis. RESULTS: In all patients, the mean age was 77.7±10.5 years. There were 140 males and 59 females. Overall recurrence rate was 7.0%. Each recurrence rate was 8.3% in the Gorei-san administration group, and 10.9% in the tranexamic acid group, and 2.9% in Gorei-san with tranexamic acid group, and 5.7% in the no-drug group. There was no significant difference between the four groups in statistical analysis. CONCLUSIONS: Gorei-san with the tranexamic acid administration group had the minimum recurrence. There was no significant difference but these drugs would be preventable recurrence of chronic subdural hematoma. We need to accumulate more cases as a prospective study in the future.

Acute calcific prevertebral tendonitis mimicking tension-type headache.

A 74-year-old woman was admitted to our hospital due to severe nuchal pain and occipitalgia. Neurological examination found neck stiffness but no throat pain or dysphagia. Blood examination showed slight elevation of white blood cell count, but C-reactive protein level was normal. Cerebrospinal fluid examination found no abnormalities. Computed tomography (CT) and magnetic resonance (MR) imaging demonstrated no abnormalities in the brain. Cervical CT showed a small calcification in front of the C1 body. Cervical T(2)-weighted MR imaging showed a high intensity area in front of the upper cervical vertebral body from C1 to C4, suggesting inflammation of the longus colli muscles. We diagnosed acute calcific prevertebral tendonitis. She was administered nonsteroidal anti-inflammatory drugs. Her symptoms gradually improved and she was discharged without neurological deficit 8 days after admission. It is important to be aware of the possibility of this rare disease in a patient with severe occipitalgia but no sign of intracerebral lesion.

Ruptured anterior cerebral artery aneurysm at the origin of the accessory middle cerebral artery.

A 36-year-old female patient was admitted to our hospital with a rare case of aneurysm at the origin of the accessory middle cerebral artery (MCA) manifesting as severe headache and vomiting. Neurological examination did not detect any abnormalities or consciousness disturbance. Computed tomography demonstrated diffuse subarachnoid hemorrhage. Magnetic resonance angiography showed an aneurysm in the horizontal portion of the left anterior cerebral artery (A(1)). Digital subtraction angiography and three-dimensional digital subtraction angiography demonstrated a saccular aneurysm originating at the junction of the left A(1) and accessory MCA. Another accessory MCA originated at the proximal portion of the left A(2) without an aneurysm. Two accessory MCAs were found on the left. Neck clipping was performed via a left pterional approach. One month after admission, she was discharged without neurological deficits.

Basal cerebral venous drainage from cavernous sinus dural arteriovenous fistulas.

INTRODUCTION: This study aimed to define the patterns of basal cerebral venous drainage (BCVD) from cavernous sinus dural arteriovenous fistulas (CSDAVFs). MATERIALS AND METHODS: Forty sets of selective angiographic data from 36 patients with spontaneous CSDAVFs (age range, 53-79 years) were retrospectively analyzed for their drainage patterns. Three types of BCVD were observed, i.e., superolateral type, BCVD via the deep middle cerebral vein or uncal vein; posterolateral type, BCVD via the superior petrosal sinus and petrosal vein; and posteromedial type, BCVD via the bridging vein and the anterior pontomesencephalic vein. MR images and/or 3D-DSA images were also reviewed when available. RESULTS: BCVD from CSDAVF was found in 12 patients (30%), and the other drainage routes included the superior ophthalmic vein in 25 (63%), the inferior petrosal sinus in 17 (43%), the superficial middle cerebral vein in 17 (43%), intercavernous sinus in 15 (38%), the superior petrosal sinus in seven (18%), and pterygoid plexus in two (5%), respectively. In 12 patients with BCVD, superolateral type was found in four (33%), posterolateral type in five (42%), and posteromedial type in seven (58%). Four cases of posteromedial type were associated with other types of BCVD. CONCLUSION: CSDAVFs are often associated with BCVD via three different pathways. The posteromedial type via the bridging vein is the most frequent type of BCVD.

The anterior medullary-anterior pontomesencephalic venous system and its bridging veins communicating to the dural sinuses: normal anatomy and drainage routes from dural arteriovenous fistulas.

INTRODUCTION: We evaluated the normal venous anatomy of the anterior medullary/anterior pontomesencephalic venous (AMV/APMV) system and bridging veins connected to the dural sinuses using magnetic resonance (MR) imaging and demonstrated cases of dural arteriovenous fistulas (DAVFs) with bridging venous drainage. MATERIALS AND METHODS: MR images obtained using a 3D gradient echo sequence in 70 patients without lesions affecting the deep or posterior venous channels were reviewed to evaluate the normal anatomy of the AMV/APMV system and bridging veins. MR images and digital subtraction angiography in 80 cases with intracranial or craniocervical junction DAVFs were reviewed to evaluate the bridging venous drainage from DAVFs. RESULTS: MR images clearly revealed AMV/APMV in 35 cases. Fifteen cases showed a direct connection between AMV and APMV, while 15 cases showed an indirect communication via the transverse pontine vein or the bridging vein. In the five remaining cases, the AMV and APMV end separately to the bridging vein or the transverse pontine vein. Bridging veins were identified in 34 cases, connecting to the cavernous sinus in 33, to the suboccipital cavernous sinus in 11, and the inferior petrosal sinus in five cases. In 80 DAVF cases, seven of 40 cavernous sinus DAVFs, two craniocervical junction DAVFs, and one inferior petrosal sinus DAVF drained via bridging veins to the brain stem. CONCLUSION: The AMV/APMV and bridging veins showed various anatomies and frequently showed a connection to the cavernous sinus. Knowledge of the venous anatomy is helpful for the diagnosis and intravascular treatment of DAVFs.

Double stent technique for the treatment of an internal carotid artery pseudoaneurysm caused by zone III stab injury.

A 77-year-old man was transferred to the hospital with swelling of his neck and oropharynx after a stab injury to his oral cavity with pruning shears. Findings at complete neurologic examination were normal. Contrast-enhanced computed tomography (CT) and angiography revealed a pseudoaneurysm at the pharyngeal portion of the right internal carotid artery. Endovascular treatment was undertaken by using the double bare stent technique. The pseudoaneurysm was completely occluded immediately after the procedure. There were no complications. There were no further symptoms or evidence of recurrence of the aneurysm during the 18-month follow-up period. The double bare stent technique is safe and effective for the treatment of zone III carotid artery stab injuries.

Unique infiltrating morphology of a meningioma-a case report.

BACKGROUND: We report on the case of a patient with meningioma that was correctly identified through biopsy. CASE DESCRIPTION: A 69-year-old woman presented with slight headache and was then examined at our hospital. Neurologic and physical examinations found no abnormality. Magnetic resonance imaging demonstrated a well-enhanced huge, dural-based, and plaque-like mass extending throughout the parietooccipital convexity and the posterior fossa. Tumors pressed the adjacent brain cortex while extending along the Virchow-Robin space. A CT scan also showed hyperostosis on the parietooccipital bone. Angiography demonstrated a vascular blush that appeared to be of a tumor-like shape. A biopsy was performed to confirm the diagnosis. The histologic findings demonstrated meningothelial meningioma with infiltration into the Virchow-Robin space. CONCLUSIONS: Many radiographic patterns of meningioma have been reported, but the present case is quite rare. The radiographic and pathologic findings in our patient are discussed.

Gamma Knife surgery for primary central nervous system lymphoma: usefulness as palliative local tumor control.

OBJECT: Although there is no established treatment for primary central nervous system lymphoma (PCNSL), therapeutic protocols involving high-dose methotrexate therapy followed, in some cases, by whole-brain radiotherapy (WBRT) have generally been adopted, and they have yielded relatively favorable results. Gamma Knife surgery (GKS) is a stopgap measure to treat patients with PCNSL. The authors summarize the results of their cases and evaluate the efficacy and usefulness of GKS. METHODS: Between June 1999, and June 2005, 22 patients suffering from PCNSL were treated with GKS at the authors' institution and were followed up for more than 6 months. Some combination of chemotherapy and/or WBRT and/or microsurgery had been performed in 18 of the 22 patients before GKS. The remaining four patients had not undergone any previous treatment. In these patients, the mean tumor volume was 4.14 cm3, and the tumors were treated with a mean margin dose of 16.5 Gy to the 52.8% isodose line. Magnetic resonance imaging demonstrated the disappearance of the GKS-treated lesions; however, new lesions were observed in other regions of the brain in 10 patients and repeated GKS was performed in some cases. No local recurrences were observed an average of 19.4 months after GKS, and good level of quality of life (QOL) was maintained during this period. CONCLUSIONS: Gamma Knife surgery should be performed only for local tumor control as a stopgap measure in the treatment of PCNSL. It is noninvasive and safe, and its effects occur rapidly. Its use improves prognosis and enhances the patient's quality of life. Gamma Knife surgery should be considered one of the treatment strategies for patients with PCNSLs.

Postoperative adjuvant treatment for pineal parenchymal tumour of intermediate differentiation.

Pineal parenchymal tumour of intermediate differentiation (PPTID) in adults is rare and a treatment strategy for this condition has not yet been established. We present a case of an elderly patient treated with postoperative adjuvant therapy using radio- and chemotherapy. This 60-year-old man presented with a 3-month history of memory disturbance, gait instability and double vision. Computed tomography and magnetic resonance imaging demonstrated a mass in the pineal region that suggested a malignant tumour. Partial removal of the tumour was undertaken via the right occipital transtentorial approach. The histological diagnosis was PPTID. Postoperative radio- and chemotherapy were administered, with a good response. Little is known about the clinical behaviour of PPTID in adults. Our treatment plan indicates one effective option for the management of such tumours.

Limitations of three-dimensional reconstructed computerized tomography angiography after clip placement for intracranial aneurysms.

OBJECT: The authors compared the usefulness of three-dimensional (3D) reconstructed computerized tomography (CT) angiography with 3D digital subtraction (DS) angiography in assessing intracranial aneurysms after clip placement. A retrospective review of clinical cases was performed. METHODS: Between May 2001 and May 2003, 17 patients with a total of 20 intracranial aneurysms underwent 3D CT and 3D DS angiography following clip placement. The authors assessed the presence or absence of residual aneurysm necks and stenoocclusive changes in the parent artery and the neighboring artery. The efficacy of CT angiographic visualization was also evaluated. In 12 of the 20 aneurysms, both 3D modalities similarly demonstrated the residual aneurysm neck and stenoocclusive changes in the parent artery and neighboring artery. Three-dimensional CT angiography failed to demonstrate three of the aneurysms, and the studies were not considered suitable for evaluation because of the presence of metallic artifacts. In the remaining five studies, the 3D CT angiograms did not effectively demonstrate the neighboring and parent arteries. The detectability of residual aneurysm necks was correlated with the clip material and with the number of clips applied. CONCLUSIONS: Three-dimensional DS angiography is still necessary in cases involving multiple clips or with cobalt alloy clips because the clips appear as metal artifacts on 3D CT angiography.

Tolerance dose in gamma knife surgery of lesions extending to the anterior visual pathway.

OBJECT: The authors performed a retrospective analysis of the radiation dose to the anterior visual pathway (AVP) to assess its tolerance to gamma knife surgery. METHODS: They examined five cases followed for more than 3 years. The AVP was treated with 10-Gy doses or higher. The mean maximum delivered dose to the AVP was 14 Gy. Ten gray or more was delivered to 25.5% of the ipsilateral AVP, 12 Gy or more to 12.5% of the ipsilateral AVP, and 14 Gy or more to 5.7% of the ipsilateral AVP. Although the mean follow-up period was 40.8 months (36-51 months), no cases of visual function deterioration developed. CONCLUSIONS: The tolerance dose of the AVP is considered to be less than 8 to 10 Gy; however, although the delivered dose to the AVP definitely exceeded the tolerance dose in all five cases, no visual disturbance has been identified. Longer follow up is required before any final conclusions may be drawn. Nonetheless, it is suggested that a visual disturbance may be avoided by using careful accurate dose planning even if the dose delivered to the AVP is higher than currently believed to be acceptable.

Treatment of intracranial dural arteriovenous fistulas: current strategies based on location and hemodynamics, and alternative techniques of transcatheter embolization.

Intracranial dural arteriovenous fistulas (AVFs) can occur anywhere within the dura mater. Patients may be clinically asymptomatic or may experience symptoms ranging from mild symptoms to fatal hemorrhage, depending on the location (eg, cavernous sinus, transverse-sigmoid sinus, tentorium, superior sagittal sinus, anterior fossa) and venous drainage pattern of the AVF. In the past, dural AVFs have been treated with a variety of approaches, including surgical resection, venous clipping, transcatheter embolization, radiation therapy, or a combination of these treatments. Recent developments in catheter intervention now allow most patients to be cured with transcatheter embolization, although stereotactic radiation therapy is demonstrating good results in an increasing number of cases and surgery is still the preferred option in some cases. Familiarity with drainage patterns, the risk of aggressive symptoms, recent technical advances, and current treatment strategies is essential for the treatment of intracranial dural AVFs.

Ruptured "blisterlike" aneurysm with a pseudoaneurysm formation requiring delayed intervention with endovascular coil embolization. Case report.

A ruptured blisterlike aneurysm of the supraclinoid ICA rarely occurs. Nevertheless, it is recognized as a dangerous lesion because of the high risk of intraoperative bleeding associated with this lesion's wide fragile neck. There has been only one report of a blisterlike aneurysm treated by endosaccular packing after surgical wrapping. The authors describe the case of a ruptured blisterlike aneurysm with a pseudoaneurysm cavity, which was treated by coil embolization. This 63-year-old woman suffered a subarachnoid hemorrhage (SAH). Three cerebral aneurysms were identified on cerebral angiograms. A large saccular aneurysm at the ophthalmic portion of the right ICA was embolized with Guglielmi Detachable Coils (GDCs). Two small hemipherically shaped aneurysms on the C-2 and C-3 portions of the left ICA were observed conservatively. Thirteen days later, recurrent SAH was identified on computerized tomography scans. Angiography demonstrated the formation of a pseudoaneurysm from the aneurysm on the C-2 portion of the left ICA. Endosaccular embolization with GDCs was performed 40 days after admission. Disappearance of the pseudoaneurysm cavity and residual dome filling was seen immediately after the procedure. Follow-up angiography performed 9 months after embolization demonstrated complete obliteration of the aneurysm. This case illustrates that when treatment options for a blisterlike aneurysm with a pseudoaneurysm are unsuitable during the acute phase, coil embolization can be applied following progression of the lesion into a saccular aneurysm during the chronic stage.